Evan G. Pivalizza

The Accuracy of Electrocardiogram-Controlled Central Line Placement

BACKGROUND:Electrocardiogram (ECG) guidance to confirm accurate positioning of central venous catheters (CVC), placed before surgery in the operating room, is rarely used in the United States. We designed this randomized, controlled trial to investigate whether the use of this technique impacts the accuracy of CVC placement. METHODS:Patients in group ECG (n = 147) had a CVC placed using right-atrial ECG to guide catheter tip positioning. CVCs in group NO-ECG (n = 143) were positioned without this technique. RESULTS:Overall, guidewire-ECG control resulted in more correctly positioned CVCs (96% vs 76%, P ≤ 0.001) without increasing placement time. Significantly more CVCs were placed in the middle of the superior vena cava in group ECG (P ≤ 0.001), although placement into the right atrium or right ventricle and into other vessels occurred significantly more often in group NO-ECG (P ≤ 0.001). Twenty patients in group NO-ECG required repositioning of their CVC after surgery, whereas this maneuver was necessary only in three patients in group ECG (P ≤ 0.001). CONCLUSIONS:ECG guidance allows for more accurate CVC placement, and should be considered to increase patient safety and reduce costs associated with repositioning procedures.

Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients.

BACKGROUND Injury leads to dramatic disturbances in coagulation with increased risk of bleeding followed by a hypercoagulable state. A comprehensive assessment of these coagulation abnormalities can be measured and described by thrombelastography. The purpose of this study was to identify whether admission rapid-thrombelastography (r-TEG) could identify patients at risk of developing pulmonary embolism (PE) during their hospital stay. METHODS Patients admitted between September 2009 to February 2011 who met criteria for our highest-level trauma activation and were transported directly from the scene were included in the study. PE defined as clinically suspected and computed tomography angiography confirmed PE. We evaluated r-TEG values with particular attention to the maximal amplitude (mA) parameter that is indicative of overall clot strength. Demographics, vital signs, injury severity, and r-TEG values were then evaluated. In addition to r-TEG values, gender and injury severity score (ISS) were chosen a priori for developing a multiple logistic regression model predicting development of PE. RESULTS r-TEG was obtained on 2,070 consecutive trauma activations. Of these, 2.5% (53) developed PE, 97.5% (2,017) did not develop PE. Patients in the PE group were older (median age, 41 vs. 33 years, p = 0.012) and more likely to be white (69% vs. 54%, p = 0.036). None of the patients in the PE group sustained penetrating injury (0% vs. 25% in the no-PE group, p < 0.001). The PE group also had admission higher mA values (66 vs. 63, p = 0.050) and higher ISS (median, 31 vs. 19, p = 0.002). When controlling for gender, race, age, and ISS, elevated mA at admission was an independent predictor of PE with an odds ratio of 3.5 for mA > 65 and 5.8 for mA > 72. CONCLUSION Admission r-TEG mA values can identify patients with an increased risk of in-hospital PE. Further studies are needed to determine whether alternative anticoagulation strategies should be used for these high-risk patients. LEVEL OF EVIDENCE Prognostic study, level III.

Changes in onset time of rocuronium in patients pretreated with ephedrine and esmolol - The role of cardiac output

Background:  We investigated the hypothesis that manipulation of cardiac output (CO) with esmolol (Es) or ephedrine (E) affects the onset time of rocuronium.

Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature: a rebuttal.

See also Romualdi E, Dentali F, Rancan E, Squizzato A, Steidl L, Middeldorp S, Ageno W. Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature. J Thromb Haemost 2013; 11: 270–81 and Romualdi E, Dentali F, Squizzato A, Ageno W. Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature: a reply to a rebuttal. This issue, pp 788–9.

Thromboelastography with heparinase in orthotopic liver transplantation

OBJECTIVE To investigate the role of heparin in the postreperfusion coagulopathy during liver transplantation with heparinase-guided thromboelastography. DESIGN A prospective, interventional study. SETTING A university-affiliated hospital. PARTICIPANTS Twenty-six patients undergoing orthotopic liver transplantation (OLT). INTERVENTIONS Blood drawn at five intervals for thromboelastography assessment with native (12 patients) or celite blood (14 patients) compared with simultaneous thromboelastography traces with added heparinase. MAIN RESULTS In the native samples, the prolonged R (reaction) and K (coagulation) time and decreased alpha angle were corrected in heparinase thromboelastograph traces immediately before reperfusion and 10 minutes postreperfusion. In the celite-accelerated samples, the heparinase traces showed correction of the R and K times and alpha angle only at the 10-minute postreperfusion stage. In seven patients who had thromboelastography performed after protamine administration, there were no differences between celite and heparinase-celite traces. CONCLUSIONS Heparinase-treated thromboelastography offered compelling evidence for the presence of heparin-like activity after liver graft reperfusion. The objective evidence provided by this modification of thromboelastography-guided protamine administration and was useful in identifying one of the many potential causes of postreperfusion bleeding in patients undergoing OLT.

An evaluation of the T‐Line® Tensymeter continuous noninvasive blood pressure device during induced hypotension*

A new continuous noninvasive blood pressure measurement device, the T‐Line® Tensymeter TL100 (Tensys Medical Inc., San Diego, CA, USA) which enables avoidance of arterial cannulation has been developed. We compared the values obtained using the T‐Line values to simultaneous arterial line measurements in patients undergoing general anaesthesia with induced hypotension. Twenty‐five patients, aged 18–70 years, were studied. The T‐Line and arterial line were positioned on the contralateral wrists. Intra‐operative, real‐time, blood pressure data were electronically captured and stored on a computer. Bland–Altman plots and 95% limits of agreement show that the majority of T‐Line data points were within 5 mmHg of the arterial line measurements (67%) and agreement was within 15 mmHg in 94.6% or more of all measurements. There was virtually no distinguishable error over the course of surgery using the device. In conclusion, the T‐Line measurements correlate with arterial measurements during anaesthesia in which there were periods of both normotensive and hypotensive anaesthesia. The T‐Line Tensymeter represents a noninvasive alternative to an arterial line in cases when arterial blood sampling is not required.

Perioperative thromboelastography and sonoclot analysis in morbidly obese patients

PurposeTo investigate perioperative coagulation in morbidly obese (MO) patients with the thromboelastograph (TEG) and Sonoclot analyzer.MethodsTwenty-six consecutive morbidly obese and 26 consecutive lean patients presenting for elective surgery were enrolled in this prospective, observational study. Blood was sampled for TEG and Sonoclot analysis immediately after anaesthetic induction and at the end of surgery in the MO group, and immediately after anaesthetic induction in the lean group. The R and K times, alpha angle, maximum amplitude and percentage fibrinoiysis at 30 and 60 min were recorded from the TEG. The Sonoclot ACT, initial clot rate, peak amplitude and time to peak amplitude were recorded from the Sonoclot.ResultsThe TEG in the MO group demonstrated decreased R and K times (8.6 ± 4.8 vs 11.7 ± 3.9 mm, and 2.8 ± 1.2 vs 3.5 ± 0.9 mm respectively (P < 0.05)), and increased alpha angle (73.7 ± 6.0 vs 66.7 ± 6.0°, P < 0.05) and maximum amplitude (72.0 ± 5.4 vs 67.9 ± 4.4 mm, P < 0.05), without change in fibrinolysis. Sonoclot variables in the MO group included increased clot rate (37.5 ± 11.5 vs 23.9 ± 7.7%, P < 0.05) and decreased time to peak impedance (11.7 ± 5.0 vs 17.5 ± 7.2 min, P < 0.05), without change in Sonoclot ACT or peak signature impedance.ConclusionThe MO group demonstrated accelerated fibrin formation, fibrinogen-platelet interaction, and platelet function compared with lean controls but no difference in fibrinolysis. Viscoelastic measures of coagulation may be useful in MO patients, who are at increased risk of thromboembolic events.RésuméObjectifExaminer le bilan hémostatique de patients pathologiquement obèses par thromboélastographie (TÉG) et analyse Sonoclot.MéthodesConsécutivement, 26 sujets obèses pathologiques (OP) et 26 sujets maigres programmés pour une chirurgie élective ont participé à cette étude prospective et observationnelle. Chez les obèses, du sang a été prélevé pour l’analyse par TÉG et par Sonoclot immédiatement après l’induction de l’anesthésie et à la fin de la chirurgie et, chez les sujets maigres, immédiatement après l’induction. Les temps R et K, l’angle alpha, l’amplitude maximale et le pourcentage de fibnnolyse à 30 et 60 min ont été enregistrés par TÉG. L’ACT la vitesse initiate de formation du caillot, l’amplitude maximale et le temps d’amplitude maximale ont été enregistrés au Sonoclot.RésultatsDans le groupe OP, la TÉG a révélé une baisse des temps R et K (respectivement 8,6 ± 4,8 vs 11,7 ±3,9 mm et 2,8 ± 1,2 vs 3.5 ± 0,9 mm, P < 0,05) et une augmentation de l’angle alpha (73,7 ± 6,0 vs 66,7 ± 6,0°, P < 0,05) et de l’amplitude maximale (72,0 ± 5,4 vs 67,9 ± 4,4 mm, P < 0,05) sans changement fibrinolytique. Au Sonoclot, dans le groupe OP, on observait une augmentation de la vitesse de formation du caillot (37,5 ± 11,5 vs 23,9 ± 7,7%, P < 0,05) et une diminution du temps d’impédance maximale (11,7 ± 0,5 vs 17,5 ± 7,2 min, P < 0,05) sans changement à l’ACT Sonoclot ou à l’impédance maximaie de signature.ConclusionDans groupe OP, la formation de fibrine, l’interaction fibrinogène-plaquettes et la fonction plaquettaire sont accélérées comparativement aux contrôles maigres alors que la fibrinolyse est identique. Les mesures viscoélastiques de la coagulation peuvent être utiles chez les obèses pathologiques qui sont à risque d’accidents thromboemboliques.

Anaesthesia for magnetoencephalography in children with intractable seizures

Background Magnetoencephalography (MEG), a noninvasive technique for evaluation of epileptic patients, records magnetic fields during neuronal electrical activity within the brain. Anaesthesia experience for MEG has not yet been reported.

Emotional intelligence and the relationship to resident performance: a multi-institutional study.

STUDY OBJECTIVE To test the hypothesis that emotional intelligence, as measured by a BarOn Emotional Quotient Inventory (EQ-i), the 125-item version personal inventory (EQ-i:125), correlates with resident performance. DESIGN Survey (personal inventory) instrument. SETTING Five U.S. academic anesthesiology residency programs. PARTICIPANTS Postgraduate year (PGY) 2, 3, and 4 residents enrolled in university-based anesthesiology residency programs. MEASUREMENTS Residents confidentially completed the BarOn EQ-i:125 personal inventory. The deidentified resident evaluations were sent to the principal investigator of a separate data collection study for data analysis. Data collected from the inventory were correlated with daily evaluations of the residents by residency program faculty. Results of the individual BarOn EQ-i:125 and daily faculty evaluations of the residents were compiled and analyzed. MAIN RESULTS Univariate correlation analysis and multivariate canonical analysis showed that some aspects of the BarOn EQ-i:125 were significantly correlated with, and likely to be predictors of, resident performance. CONCLUSIONS Emotional intelligence, as measured by the BarOn EQ-i personal inventory, has considerable promise as an independent indicator of performance as an anesthesiology resident.

Celite-activated thrombelastography in children

STUDY OBJECTIVE To quantify global coagulation and establish normal ranges for the celite-activated thrombelastograph (TEG) in healthy pediatric patients. DESIGN Prospective observational study. SETTING Operating suite of a university-based hospital. PATIENTS 110 healthy pediatric patients in four age groups and 25 healthy adult patients. INTERVENTIONS Blood sampling for the celite-activated TEG was carried out after anesthetic induction. MEASUREMENTS TEG indices: R time (reflecting time to fibrin formation), K time and alpha angle (fibrinogen-platelet interaction), maximum amplitude (reflecting maximal clot strength, platelet and fibrinogen function), TEG index (mathematical incorporation of the prior four measurements), and percent fibrinolysis at 30 minutes, were all recorded. MAIN RESULTS Statistically significant differences between <12-month group in angle (compared to 25-48 month group) and % fibrinolysis (compared to all other pediatric groups). Significant differences in angle between two pediatric groups and adult group, and in the TEG index between three pediatric groups and adult group (all differences p < 0.05). CONCLUSIONS These data identify changes of small magnitude in three celite-TEG parameters in healthy children compared to adults, without implication of abnormal coagulation between groups. Changes do not seem to be consistently related to age and will be useful for clinicians using the TEG to monitor (ab) normal coagulation in pediatric patients.